Intraoperative correction of hemodynamic instability in patients with pheochromocytoma

Abstract

Aim. Development, clinical evaluation and implementation of intraoperative hemodynamic monitoring system to ensure the modern anesthetic management of laparoscopic adrenalectomy in patients with pheochromocytoma in a specialized endocrinology center based on the algorithm of staged perioperative hemodynamic management (SPOHM).Materials and methods. We performed the analysis and comparison of hemodynamic parameters at the stage of selection of the tumor of the adrenal gland, after the clip overlay and intersection v. Centralis in 33 women operated for pheochromocytomas during 2013-2016 in the department of endocrine surgery of Ukrainian Scientific and Practical Center of Endocrine Surgery, Transplantation of Endocrine Organs and Tissues of Public of the Ministry of Health of Ukraine. Adrenal pheochromocytoma was removed by minimally invasive technologies — video-assisted laparoscopic adrenalectomy.Results and discussion. All patients had significantly (p <0.001) increased levels of daily urine metanephrines to 1831.6±337.9 mg/24 h (control – 169.3±12.7 mg/24 h). In accordance to the SPOHM algorithm we used doxazosin 10.0±1.0 mg or urapidil 144.0±11.2 mg in 2 divided doses in the first stage. In a second step we performed hemodilution using 10% solution of HES (200/0.5) and controlled antihypertensive therapy by infusion of urapidil with an average speed 9.7±1.9 mg/hr. In the third stage intraoperative infusion rate of urapidil was 1.25±0.08 mg/min (at the moment of surgical separation of adrenal pheochromocytoma optional bolus of urapidil 25-50 mg was administered if even the slightest increase in blood pressure appears). After removal of the tumor we observed stabilization of hemodynamic parameters in the absence of significant hypotension. Sympathomimetics were not used. In the fourth stage prevention of adrenal insufficiency and hypovolemia was performed.Conclusions. The introduction of anesthetic management of patients with pheochromocytoma in the specialized endocrinology center provided high efficiency and safety of hemodynamic monitoring in laparoscopic adrenalectomy. The SPOHM algorithm in preparation for surgery and during surgery is an effective, easy to manage and secure method of hemodynamic parameters stabilization.